Form None. Version 2 - Statistical Report and Instructions

OMB Control No. 1076-0135 (Version 2)

Expiration Date XX/XX/XXXX

Public Law 102-477 Statistical Report
Tribal Nation		Report Period
		From:	To:
I. Participants Served	Adults	Youth	Cash Assistance Recipients
A. Total Participants
B. Total Terminees
C. Total Current Participants
II. Terminee Outcomes	Adult	Youth	Cash Assistance Recipients
A. Total with Employment Objective
1. Entered Unsubsidized Employment
2. Other Employment Outcomes
3. Employment Objective Not Achieved
4. Average Adult Earnings Gain
B. Total with Educational/Training Objective
1. Degree/Certificate
Attempted
Attained
2. Other Education Outcomes
3. Education Objective Not Achieved
C. Misc. Objective Achieved
D. Other (Non-Positive)
III. Terminee Characteristics	Adult	Youth	Cash Assistance Recipients
A. Female
B. Male
C. Education Level
1. Dropout
2. Student
3. High School/Diploma/GED
4. Post High School
D. Veteran
IV. Participant Activities	Adult	Youth	Cash Assistance Recipients
A. Employment
B. Education/Training
C. Misc. Objective/Supportive Services
D. Other/Service Referral
V. Child Care and Development Activities	Families	Children	Cash Assistance Recipients
A. Families Receiving Child Care
B. Children Receiving Child Care
1. Ages 0 through 3 years
2. Ages 4 through 5 years
3. Ages 6 through 12
4. Ages 13 and older
C. Care Received – Type of Provider
1. Center Based
2. Family Child Care Home
3. Group Home
4. Child’s Home
VI. Jobs Creation/Economic Development	Jobs Created	AI/AN Employed	Businesses Assisted
A. Number
Report Prepared By (Print Name & Sign)	Phone Number		Date

Public Law 102-477 Program Statistical Report

INSTRUCTIONS

Purpose: The attached Program Statistical Report is one of three parts of the statutorily integrated annual report for Pub. L. 102-477. The report provides statistical summary data of participants receiving any of the services available under the initiative. The data includes current participants and those terminated from the program identifying outcomes, characteristics, activities, goals and objectives. Participants are categorized as either adult or youth or cash assistance recipients. Summary data is also collected for child care services identifying the number of families involved, the ages of children and type of child care provider. Finally, the report provides economic development data including number of jobs created and businesses assisted. Response to the statistical summary is mandatory and in accordance with Pub. L. 102-477. In order to provide standard, meaningful data on the initiative as a whole, each tribe’s statistical summary will be provided in a uniform format. Statistics listed are reported by program services and activities, in accordance with the Pub. L. 102-477 plan, not by fund source.

Identification Section: Provide the name of the tribe/grantee along with the report period. The report period should be one year unless a formal written request has been requested and approved in advance.

I. Participants Served (Employment & Training Services): This section includes all participants receiving services under Pub. L. 102-477 except for children receiving child care.

A. Total Participants: For this report, include those individuals who have completed an application form, have provided all of the documentation required, and have been determined eligible for participation in the tribe’s Pub. L. 102-477 initiative. The individuals are participants in the program and have begun to receive services, which may include assessment, job referral, counseling, employability planning services, placement in a job, enrollment in education or training, or related services. Individuals should not be terminated each year and then re-enrolled. Once an individual is determined eligible to receive services, the participant should continue enrollment until successfully completing or dropping out of Pub. L. 102-477 services.

• Adults: If the participant is 22 or older at the time of enrollment in the program, the participant should be counted in the first column labeled, “Adult,” except for persons receiving cash assistance.

• The age of the participant at time of enrollment into the program should be used to determine whether a participant is an adult or youth.

• Youth: If the participant is 21 or younger at the time of enrollment in the program, the participant should be counted in the second column labeled “Youth,” except for persons receiving cash assistance.

  • The age of the participant at time of enrollment into the program should be used to determine whether a participant is an adult or youth.

• Cash Assistance Recipients: “Cash assistance” means General Assistance Funds originating from the Bureau of Indian Affairs, cash assistance from the Temporary Assistance for Needy Families program, Department of Health and Human Services, or other cash assistance from the Bureau of Indian Affairs or Department of Health and Human Services. Regardless of age, if the participant has been determined to be eligible for, or is receiving cash assistance the participant should be counted only in the column labeled Cash Assistance Recipients. Individuals receiving cash assistance at any time during enrollment in a Pub. L. 102-477 project, or within 6 months prior to enrollment, should be included in this column. For example, if a participant receives cash assistance at the time of enrollment, is placed in a job, and continues with supportive services for 90 days, the individual should be counted as a cash assistance recipient because during enrollment cash assistance was received during enrollment.

• The sum of the numbers in the “Adult,” “Youth” and “cash assistance recipients” columns of the “Total Participants” row should equal the total number of participants.

B. Total Terminees: For this report, those participants that have either successfully or unsuccessfully ceased enrollment in the tribe’s Pub. L. 102-477 initiative should be counted in this section. Do not terminate participants at the end of each year and then re-enroll them. Participants should only be terminated and counted when they cease receiving services. Do not count children in child care.

• Adults: If the terminee is 22 years of age or older, the terminee should be counted in the column labeled “Adults,” except for cash assistance recipients.

• Youth: If the terminee is 21 years of age or younger, the terminee should be counted in the column labeled “Youth,” except for cash assistance recipients.

• Cash Assistance Recipients: If the terminee was a cash assistance recipient at any time during participation in Pub. L. 102-477, or within 6 months prior to participation, the terminee should be counted in the column labeled “Cash Assistance Recipients” instead of the “Youth” or “Adults” columns.

C. Total Current Participants: For this report, total current participants includes all participants who are considered to have been served at any time during the reporting period, but have not yet completed and terminated from the program as of the last day of the report period. The sum of Total Current Participants and Total Terminees should equal the number of Total Participants.

2. Terminee Outcomes: In this section, only count those participants who have ceased participation in the tribe’s Pub. L. 102-477 initiative at any time during the reporting period. Count terminees whether or not they have been successful in meeting their stated short or long-range goals. The information can be recorded at any time within 90 days following the person’s completion of or other termination from the program. Terminees may be counted more than once in total, but not more than once in each of the positive termination categories (i.e. Employment Objective, Education/Training Objective) except that a terminee may be counted more than once in the positive termination category for Miscellaneous Objective Achieved if the terminee achieved multiple miscellaneous objectives). Terminees counted as “Other (Non-Positive)” may not be counted in any of the three positive termination categories.

1. Total with Employment Objective: Count all participants who included an employment objective in their individualized service plan and have ceased participation in the tribe’s Pub. L. 102-477 initiative at any time during the reporting period..

1. Entered Unsubsidized Employment: Include the number of terminees who have entered employment and do not receive a subsidy. Include self-employment in this count.

2. Other Employment Outcomes: Include the number of terminees who met an employment objective. This includes participants who have been successfully assisted in retaining an existing job with supportive services or successfully completed an OJT assignment but were not retained in employment.

3. Employment Objective Not Achieved: Include the number of terminees who had an employment objective but did not meet any of their employment goals.

4. Average Adult Earnings Gain: For those adult terminees entering unsubsidized employment, calculate the hourly wage at the last job held within the six months prior to Pub. L. 102-477 enrollment and compare that rate with the hourly wage earned at time of termination from this program. Terminees unemployed for the entire six months prior to entering the program should be considered to have $0 per hour rate at entry. To illustrate, if at termination such a person entered unsubsidized employment earning $6.50 per hour, the gain would be $6.50 per hour. Add all gains and subtract any losses. Divide this number by the number of adult terminees entering unsubsidized employment. The result will be the average gain.

2. Total with Educational/Training Objective: Include the number of participants who had an educational/training objective and have ceased participation in the tribe’s Pub. L. 102-477 initiative. Include terminees gaining knowledge such as completing a semester or more of classes or long or short-term classroom training measurement.

1. Degree/Certificate Attempted/Attained: Include two numbers here. Include both the number of terminees who attempted to earn a degree or certificate and the number of terminees who successfully attained a degree or certificate. Include those terminees who have completed a full course of study and received certification or degree recognition in the Attained number.

2. Other Education Outcome: Report the number of adults and youth terminees and cash assistance recipients who met an educational goal other than attainment of a certificate or degree.

3. Education Objective Not Achieved: Report the number of adults and youth terminees and cash assistance recipients who had educational goals but did not meet any of them.

3. Misc. Objective Achieved: report the number of terminees that met one or more of their short or long-term goals not related to employment or education here. For example, a terminee may have acquired a driver’s license, or may have applied for other supportive services as a goal, e.g. LIHEAP.

4. Other (Non-Positive): Report only the number of terminees who failed to meet all of their short-term and long-term goals as stated in their development plan. If a terminee met one or more of his or her goals but not the final goal, he or she should be counted in A, B or C above.

2. Terminee Characteristics: Only count those terminees who have had their case closed and were included in I - B above (Participants Served, Total Terminees). Do not include characteristics of all participants.

A. Female: Report the number of female adults (22 and over) and youth (21 and younger) and cash assistance recipients.

B. Male: Report the number of male adults (22 and over) and youth (21 and younger) and cash assistance recipients.

The number of females and males in each column (adult and youth, and cash assistance recipients) should equal the total number of terminees in the same column.

C. Education Level at Intake:

1. Dropout: Terminees who, at the time of enrollment into the program, had not attained a high school diploma or GED and were not attending school. If they received a GED during participation in the program, the terminees should still be counted as dropouts because they were dropouts at enrollment.

2. Student: Terminees who, at the time of enrollment into the program, were enrolled in any level of formal education.

3. High School Diploma or GED: Terminees whose highest level of educational attainment at the time of enrollment in the program was a high school diploma or GED, if they are receiving cash assistance any time during participation, or within 60 days prior to enrollment in Pub. L. 102-477 services.

4. Post High School: Terminees whose highest level of educational attainment at the time of enrollment in the program was greater than a high school diploma or GED and were not enrolled in any level of formal education.

The sum of the numbers reported in the education level section should equal the total number of terminees reported in Section I.B.

D. Veteran: Count all terminees that have served in the military and are considered veterans.

IV. Participant Activities/Goals/Objectives: For all participants, whether current or terminated, record the type of activities, goals and objectives established for participants through an Employment Development Plan. If a participant has been involved in more than one activity, goal or objective, count that participant once in each category that applies. The total number of adults and youth, and cash assistance recipients may be greater than the total in Section I above.

A. Employment: Report the number of adult and youth, and cash assistance recipients who engaged in employment activities such as job referrals, work experience, job interviewing, supportive work services and other job-related goals.

B. Education/Training: Report the number of participants who were engaged in any educational or training activity, including On the Job Training, Adult Basic Education, GED preparation testing and related services.

C. Misc Objective/Supportive Services: Report the number of adult and youth, and cash assistance recipients who participated in non-employment and non-education activities. Such non-employment, non-educational activities may include transportation assistance, housing assistance, assistance in obtaining a driver’s license, child care when furnished to adults as supportive services, and similar assistance.

D. Other/Service Referral: Any other services or referrals should be counted here.

The totals for A, B and C above may not equal the number of participants served. The total will probably be much higher since some participants may receive numerous services while enrolled.

V. Child Care and Development Activities:

1. Families Receiving Child Care: Count the total number of family units and total number of children provided with child care services that are funded through the tribes Pub. L. 102-477 budget.

B.1-4 Children Receiving Child Care: Count of total number of such children served. The four age categories will add up to the total number of children shown receiving child care. These child care services include any such services provided through the program, regardless of whether the programs Pub. L. 102-477 budget includes funds from formal child care programs, such as the Child Care and Development Fund program.

B.4 Ages 13 and older: For CCDF purposes, a Tribe may serve children age 13 and above who are physically and/or mentally incapable of self-care, or under court supervision. However, the upper age limit may not be over age 19.

C.1-4 Care Received-Type of Provider: A child may be counted in more than one provider line (Lines C.1 – C.4) if the child receives care from more than one provider type for different portions of the typical day, week, or month.

VI: Job Creation/Economic Development:

Jobs Created: Count the number of new jobs (not participants) which were created as a result of your Pub. L. 102-477 program. Only count those jobs that did not exist before the 477 program helped create them. The count includes jobs created at a new or expanding business that received on the job training support.

American Indians/Alaska Natives Employed: Count the number of additional American Indians/Alaska Natives who were employed as a result of the jobs created (and reported in the previous line item).

Businesses Assisted: Provide the number of business that the Pub. L. 102-477 program assisted. This may include businesses assisted through supportive services such as counseling services for existing employees, training for employees of businesses, on-the-job placements, recruitment and advertisement of positions, and related support. Count all businesses assisted. Do not limit the count to tribal businesses or individual tribal members’ businesses.

Report Prepared by: Please provide name and phone number of person completing the report and date the report. If we have any questions regarding the report we may contact the individual.

Paperwork Reduction Act Statement

The information being collected meets the requirements of Public Law 102-477 for program evaluation, compliance, audit and program planning and management purposes. The data collected is shared with all participating Federal agencies providing funds. The reports are used to monitor the progress of the grantees in delivering services to tribal members, to identify unmet needs, to identify any other problems, and to provide information to justify budget submissions by the three federal agencies involved. Only tribes who have voluntarily applied to participate in this project will submit the annual report. Response is required to obtain benefits of the program. This report takes about 20 hours to complete. An agency may not request or sponsor a collection of information, and a person is not required to respond to a request, if a valid OMB control number is not provided. Comments concerning this information collection can be sent to: Information Collection Clearance Officer, Office of Regulatory Affairs – Indian Affairs, 1849 C Street, NW, Mail Stop 3642, Washington, DC 20240. Please note: comments, names and addresses of commenters are available for public review during regular business hours. If you wish us to withhold this information, you must state that prominently at the beginning of your comment. We will honor your request to the extent allowable by law.

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